Commentary — December 2017
Tex Med. 2017;113(12):13–14.
By Gerard J. Voorhees, MD
Let's face it: When our patients are not responding to curative treatment or are nearing the end of their lives, our interactions with them often become uncomfortable.
We are trained to maintain health and to fight illness, but our medical training does not usually equip us with the skills to have difficult conversations regarding end-of-life care options and decisions.
In his commentary in the August 2017 issue of Texas Medicine, Lawrence O'Brian, MD, referred to a Kaiser Family Foundation survey in which "9 in 10 adults (89 percent) say doctors should discuss end-of-life care issues with their patients, yet only 17 percent of adults say they have had such a discussion with their doctor or health care provider. Among adults ages 65 and older, the share is somewhat higher (27 percent)."
Renowned New Yorker writer and Boston surgeon Atul Gawande, MD, offers a perspective that challenges many traditionally held notions about the role of medicine. In his book, Being Mortal: Medicine and What Matters in the End, he observes that medical professionals are focused on disease, not on living, and that rather than ensuring health and survival, our job is "to enable well-being."
Richard Balaban, MD, offers a four-step approach to conducting end-of-life discussions in "A Physician's Guide to Talking About End-of-Life Care," published in the March 2000 issue of the Journal of General Internal Medicine. In it, Dr. Balaban proposes that we go beyond our narrow focus of resuscitation and address the broad array of concerns that most people with serious illness fear.
Talking about dying is not easy, but it is important. When it comes to end-of-life care, one conversation can make a difference. In collaboration with the Institute for Healthcare Improvement, "The Conversation Project" offers guidance in talking with people about their wishes, with the focus being on "what matters to you, not what's the matter with you."
The Centers for Medicare & Medicaid Services has recognized the importance of advance care planning (ACP). Effective Jan. 1, 2016, under the Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System, hospitals, physicians, and other practitioners can use Current Procedural Terminology codes 99497 and 99498 to file claims for ACP.
The development of a treatment plan for a person with a serious illness should be a patient-centric decision, and good communication can help facilitate a plan that is both medically sound and aligns with the patient's wishes and values. Most of us would prefer to die at home, but the majority of us are dying at hospitals and institutions. There is a huge disconnect between what we want and what really happens.
To improve care delivery to a patient with advanced cancer and other chronic diseases and progressive illnesses, the integration of palliative and supportive care is invaluable as a companion treatment, not a last resort. Studies show that people who receive palliative care report less depression and happier lives, and early access to palliative care seems to prolong life by several months, even though patients tend to opt for less-aggressive care as they near death.
Priorities become maximizing time with family and friends, minimizing pain and symptoms, maintaining functionality, and avoiding unnecessary procedures and hospitalizations. As access to pain medication becomes an increasing concern, palliative care may become concomitant.
Studies also show that after palliative care consultations, patients spend less time in the hospital and make fewer trips to the emergency room, and the use of invasive procedures decreases almost by half. Their median stay in hospice is typically longer when compared with the non-palliative care patient, offering more time to provide that level of care and services.
Palliative programs follow an interdisciplinary team approach to address the mental, emotional, and spiritual dimensions that are inseparable from one's physical health. Many people benefit from the extra time to address life-closure issues and from the additional layers of support not only for the patient, but also for the family and caregivers.
New molecular or immunologic drugs can sometimes offer a person a few months of progression-free survival. The cost is exorbitant, but again we are challenged with similar dilemmas: Can you put a price on life, especially if it is a life with quality? Two to three months is a long time for a person with advanced cancer.
In her commentary in Texas Medicine in June 2017, Angela Nguyen, DO, discusses the "medical futility" of a 92-year-old patient with colon cancer and end-stage renal disease who required multiple blood transfusions (draining the blood bank), and yet the patient declined hospice as she believed the transfusions made her quality of life better. Dr. Nguyen concludes, "Who is to say that her life isn't as valuable as anyone else's or that she is less deserving of blood transfusions than anyone else who exhibits a hemoglobin lower than 7 g/dL?"
These scenarios likely will increase as our nation struggles to develop a health care system that is universal, comprehensive, and affordable. These scenarios also make it imperative that palliative care and supportive care physicians and oncologists (as well as primary care and other specialists) collaborate to get the best outcomes.
Community-based palliative care programs will help people on this difficult journey address end-of-life issues in the home setting. Together, we can support their hopes for peace and dignity throughout the course of illness and give them a chance to live better with as much quality of life and well-being as possible.
Gerard J. Voorhees, MD, is a radiation oncologist in Corpus Christi.
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